kristo

I don't think this is the same subject. I'm not asking if EMT-B's can function as medics, I'm not questioning the need for proper education for EMS providers and I'm certainly not questioning that most medics would want a fully fledged partner, not just a driver. What I'm asking your opinion on is an EMS system with very low call volume, in which a doctor will be the primary care giver, accompanied by a driver and a tech assistant (EMTs). The EMTs are not being asked to be the physicians eyes or ears, merely provide an extra hand when the physican needs it. The physican will always be physically on scene, in the ambulance, working on the patient.

Okay, I'll rephrase the question. Do you think an EMS system where the medical director only wants to use the EMTs as extra hands and nothing more can work, as long as the extra hands (the EMTs) are fine with it, as well as the MD, who, in this case, is the actual care-giver? In this case, the medical director is on scene, so any technical problems related to communication and patient assessment through lay-persons are bypassed. I'm not asking for another "EMTs should be able to diagnose and decide upon advanced treatment" debate here. And even if I was, we sure could use one. The City's been awfully quiet lately...

While some EMTs/paramedics (certainly seems to be a majority here) wants to advance their trade as an independant medical profession, this ambition seems to vary in quantity or quality. The reason I'm bringing this up is the state of EMS in rural Iceland. In the capital city, where most of the people live (200,000 out of 300,000 total), we have a good system. However, in many rural areas, we do not. We don't have volunteer EMS, but in areas where the call volume is not very high (eg. one call a week or even less), EMTs do "normal" shifts where they get 30-45-90% salary (depending on the time of day/weekend/holiday) just for being able to come in immediately if there's a call. If there's a call, they get normal EMT salary for at least four hours. Those guys will usually have another job, where they have an arrangement with their employer, so they can leave if needed. Now, the problem with this is, of course, education - not everybody has even an EMT-B certification. Problem no. 2 is the government not wanting to pay for more than one EMT on call at a time. Until about a week ago, this was a fact in two places. Press got to it, and the government all of a sudden assigned a bit more money, so now there's always two EMTs on call. :roll: In those rural areas, it is customary for a doctor to respond with EMS. When there was only one EMT, the doctor would attend the patient in the back, without any assistance. Now, and in all other areas, the doctor would attend with the help of an EMT (without cert, EMT-B or even EMT-I). Now, in those areas, EMTs seem to be content with this, and don't see any reason for more education, as the doctor is there to make all the decisions. The doctors tend to train them in advanced procedures like IVs, intubatons, CPAP, etc., which they will perform if the doctor asks them to. They do not see anything wrong with performing those procedures without the education, as the doctor is there to make the call. Now, I'm not really sure what I feel about this (not that I have any influence in the matter ) On one hand, the education is there, with the doctor. On the other hand, there are people performing procedures they do not understand... What do you guys think?

That's what I thought, until I got it for my allergic asthma - worked withinin 2 minutes. They had some brand name like "Solu-med" or something like that, they were definately corticosteroids (they told me), so I'm assuming it's Solumedrol (methylprednisolone). Anyway, I was just agreeing with the poster that there were other possibilites, but I still maintained that epi was the best one. I'm assuming you mean his vessels were so constricted the epi wouldn't have made it to the systemic circulation system? Now, please bear in mind that my education here is only elementary (1 year down, 5 to go...), why do you think the patient was shut down peripherally, and how deep would he need to go? Deeper than the needle in an epi-pen could go in the shoulder or thigh? 100% agreed. As I stated in my post, his system needs better EMS, as in better ALS availability. However, if/while they are stuck with EMT-B's transporting patients who could have a respiratory arrest for 20 minutes, I still think it's worth the risk to let them use epinephrine, as there is simply not a lot to loose - but everything to gain. In this case, even if the epi would have been ineffective, it would still be very unlikely to do any harm.

Doesn't sound like a very good tiered system, he did not get ALS when he needed it. He performed excellent patient care within his scope, realising, however, that what the patient needed was not within his scope. This means those guys need to find a better way to provide their patients with ALS - in this case, a patient in need did not receive it. We've kicked the shit out of that dead horse, so I won't bother to stress the point, that BLS was not appropriate in this situation (although the OP seems to have done very good, considering his education/scope of practise). While, however, we have EMT-B's out there with patients who are falling into respiratory arrest due to asthma, I'd rather give them (the EMTs) epi, rather than letting the people die in the truck. Because if the airway is constricted due to asthma, you will not be able to "maintain an airway" with OPAs, the combitube or King airway device you mentioned, or even an endotrachial tube, because the constriction is in the bronchioles, lower than even the ET goes. You need bronchodilators. Epi is not the only thing, the corticosteroid solumedrol (methylprednisolone) IV works fast and lasts long, but has a potential for nasty side effects...a lot of other stuff exists. Epi, however, is easy to administer from the epi-pens, I'd think that would be the best choice for someone in respiratory arrest. Especially if you're going to give it to an EMT-B. True, sometimes it doesn't work, there are examples of people using OTC pills that contain a little epinephrine for their asthma and hence need higher dosages for it to work, as they get "used to" the epi. The thing is, if it's a respiratory arrest due to asthma, and there's no help for 20 minutes, you don't have much to loose... See my comment above on the airway devices. Nice work though, csuprun.

First of all, yes, this patient needed ALS. Yes, there should not be any BLS/ALS seperation in health care workers because all of them should be educated enough to provide ALS (the BLS/ALS distinction, by the way, is obsolete, IMHO, as it is skills-based, not education-based). All that aside, where there is only BLS available, they should be able give asthmatics in respiratory arrest epi. An appropriate dosage is available in epi-pens (0.3 mg), but the "official", as far as I know, is 0.01 mg per kg body weight up to 50 kg (0.5 mg epi). For really long transports, consider oral corticosteroids like prednisone (40-60 mg). After getting that protocol through, though, they should start working on educating their staff up to ALS level so that they don't need to let BLS providers provide semi-ALS... In Iceland, anyone with a first responder course plus a little workshop on anaphylaxis and asthma can do this, there's a protocol issued by the surgeon general...I realize this is "a bit" extreme.

I believe, at one point or another, many of us were whackers. I'm curious as to when this was, how did it manifest itself, and how you got out. I'll start. My roots are in volunteer search and rescue. When I first started, I liked patches from courses I had completed, like "Wilderness First Responder", and later "Wilderness EMT", and put them on my uniforms. I had a 65 L Conterra "ALS Extreme" backpack in the trunk of my car, even though my level of training was only EMT basic. It contained fluids, IV sets, trauma stuff, some OTC pain killers and antihistamines, epi pens, corticosteroids (prednisone). I went looking for an accelerated EMT-I course (didn't find one, luckily). I whined about professional EMS and fire "invading" our turf by establishing dive teams, fast boat rescue, and wilderness EMS. Gradually, I grew up, and decided I wanted to be a health professional, not a whacker, so I finished college in night school and am now a full-time medical student (just finished first year).

You might want to get the BRS (Board Review Series) anatomy (by Chung) and/or physiology (Constanza) books. They're small, concise, and contain only the most important points. You will probably need other resources when you start (eg. the head and neck part in the BRS anatomy book is useless), but this should give you a start, at least what to expect. Also, the "Made Ridiculously Simple" books are supposed to be good. I've ordered them from Amazon, but I haven't gotten them yet. "Clinical Anatomy Made Ridiculously Simple" especially, is supposed to be very good. It uses mnemonics a lot, in fact, the mnemonics in common use, like Some Lovers Try Positions That They Can't Handle for the carpal bones and Ron Beats Bad Men for the contents of the cubital fossa, come from that book.

That's right, i.e. methanol's metabolites are lethal. Methanol becomes formaldehyde, which damages the retina, making you blind, and breaks down further into formate, which is a neuropoison, if I recall correctly.

OK, not quite as large as I remembered. :-) From the diagram, it seems that the rescuer should be kneeling. Here's a picture of it in the package: Me holding it (for scale): The instructions on the package: The package, along with an old first-aid kit:

I also think what you're describing is too small. This thing seems to be designed to be used by a standing rescuer on a supine patient.

I'll post a picture this evening. The package even has a diagram on how to use it... Rid, if you carried that thing around, I bow to your (former) advanced whackerness - it's not exactly "pocket-sized"...

I came across a strange device in the headquarters of my SAR unit yesterday. It was a tube, one end was similar to an OPA. From that end, there was a "trunk", out of which one long tube came, and another, much shorter one. According to a diagram on the package, one was to put the "OPA part" in the patients mouth, put ones thumb on the short trunk, blocking it, and blow into the long tube. Needless to say, this thing was just on display with old first aid stuff, not in active use. I might go there again soon with a digital camera and post a photo, but have any of you seen this device before?

I completely agree. One question, though. Would you like to see the education of an American RN reach European standards, as well, or would you use the American RN model as a foundation for this new paramedic? As I understand it, RN is a 2-3 year college degree in the US. Here, it's a 4 year university degree, after college. This varies a lot within Europe, but the above is at least true for the Scandinavian countries.

Hehe, this reminds me of the village which I grew up in. A small village (approx. 300 people), a hybrid fire dept (paid per call, but had other jobs and responded on a similar basis as volunteers) with one 1961 Bedford fire engine (I'm born in 1983, so even then, the engine was old). When there was a fire, whoever noticed it was to go to the fire department building and push a button on the outer wall. This activated an old air raid siren. When it sounded, everyone in the village dropped whatever they were doing and started driving around and looking for the fire. If they found it, they stood around and waited for the fire dept. The fire dept. went to the firehouse, got the engine, and did the same (drove around the village, looking for the fire). As for EMS, provided by a town 30 minutes away during summer, sometimes completely unavailable during winter (7-9 months a year), as the village is rather isolated by mountains and due to snow, the road was usually only open one day per week (courtesy of Icelandic Road Administration :? ) We did have volunteer SAR, though. My mother was actually transported across the mountain in January 1988 by ICE-SAR in a snow mobile, in labour. They reached the hospital in time and my little brother was born there. In the early nineties, though, my father had a heart attack, and had to wait for several hours without medical attention, for the way across the mountain to be opened. Luckily, he survived. This got better over the years, now there's a 15 km tunnel through the mountain, fire/PD/EMS provided by the same town as before, but now it's 15 minutes away (through the tunnel) and available 24/7 all year long, and dispatched/controlled by the country's single dispatch centre that controls all EMS/fire/SAR/PD/coast guard/etc.

Well, since you ask. Yes, I do. In fact, I regard anyone who privately owns a scanner a whacker. For some weird reason, Americans seem to find it not just legal, but also morally defensible to let anybody listen in on fire/PD/EMS communication, thereby sacrificing patient privacy and creating a more difficult environment for emergency workers. Needless to say, here, anything that could hack into those communications (which are encrypted and generally conducted via TETRA) would be illegal. This post may sound harsh, but I feel very strongly about this and I am surprised that so many of you regard it as acceptable that anyone could legally be listening to you when you are sending or receiving sensitive information. Edit: I scored 0% on the whacker scale...but then again, scanners are illegal, so are emergency lights on private vehicles, I never wear clothing that is given to people as an advertisement (like in trade shows) and I don't like the ICE-SAR uniform well enough to wear it unless needed... 8)

Ahh. There have been discussions on an expanded scope of practice for EMS, but I did think the polymerase chain reaction was a stretch...

Okay, I'll be the one to ask. What is PCR? In my world it's polymerase chain reaction, a method in molecular biology to amplify a preselected bit of DNA (genomic or complementary) to study gene expression (like in tumors vs. normal tissue) or for looking for gene mutations...

So, inward, then (facing medially from the shoulder)?

Yes, we do have a somewhat different system. Here, we do have to finish four years of what is akin to the American college concept (similar or just more than an American associates degree), and after that, we can take an entrance examination in order to get into medical school. My major in "college" was natural sciences, I believe it was so with an overwhelming majority of medical students. Medical school here is six years, which may or may not include one year of internship, which is a set of fixed rotations (commonly divided between internal med, surgery, psychiatry, neurology, pediatrics, and OB/GYN). Before getting a full license as a physician the internship will have to be completed, it is either a part of the school's 6-6,5 years, or taken after the sixth year as part of the curriculum, depending on the school. Nursing is pretty much the same, except it's four years in university, after college. Same goes there, people don't get far in nursing without majoring in natural sciences. In the American model, medical students usually start their residency immediately after medical school, and the residency includes their internship year, specialized in their chosen field. Like I said earlier, here, the internship is mixed and a part of the medical school curriculum. Here, a new doctor will usually work for a few years before choosing a residency, to get some experience. Those doctors are called "department doctors", and will usually work at a hospital under the guidance of specialist doctors (I believe "attending physicians" is the American term, called consultants in the UK). Residencies typically take longer than in the US, too, for example, a specialization in general practice (family practice) takes five years. Specialization for nurses is usually less, 0,5 - 2 years, depending on their chosen field (after their four years in nursing + a few years work experience). ...and since Icelandic EMS is generally convinced anything that comes from Pittsburgh must be good, they're all over it. NREMT is the golden standard, believe it or not. Most ALS EMS is provided by NREMT-I's (in major urban areas, people are hired in from the street, trained as EMT-B's, can start EMT-I in about two years, required to get certified before 3 years on the job, paramedic certification encouraged, payed for for a few chosen ones after a few years as EMT-Is, but that requires a trip to the US, since we don't have any paramedic schools here). Luckily, EMS in Iceland traditionally has doctors responding with EMS to most ALS calls. The rule of the thumb is that anything including respitory distress, young children, chest pain, big trauma, etc. warrants a doctor as a third person on the ambulance. Coast guard helicopters (the government's only helicopters, so used for law enforcement, medevac, SAR, anything) are always staffed with one ER doc + one EMT-B when flying, just in case there's an EMS call requiring medevac. Of course. My roots are in volunteer SAR. When I completed my Wilderness First Responder class (NREMT FR + 30 hours of wilderness "medical" training), I was convinced that I could save the world all by myself, given that I had the blue WFR patch firmly sowed on the shoulder of all my SAR uniform stuff. I saw clearly then, how the traditional 40 hour wilderness first aid training given to SAR members was in no way sufficient. After 1,5 years as a WFR, I went to a 181 hour Wilderness EMT course in the US - termed overeducation by many of my peers in SAR - and then I realized that after WFR, I knew just enough to be dangerous. At this point, I got two patches, NREMT-B and W-EMT, which I proudly wore instead of the (now lame) WFR patch. At this point, I also got a duty belt filled with stuff I would never use, but made out of black nylon, which totally justified it's weight, and a whacker bag for my car, a 65 liter medical backpack, filled with various stuff around and above my level of training. Needless to say I almost never used that thing, as I preferred to go light on calls that included walking, and as my specialty in SAR was sea rescue and diving, and I didn't want to expose my whacker bag to the salty sea... I grew up, luckily, sold my whacker bag to the SAR team, lost my duty belt (I tend to deny its existence nowadays) and removed the patches from my shoulders. I was still interested in medicine, so I completed college in night school and went to medical school. Now I'm realizing every day how little I know.

...or teaches it. Don't you guys have any paramedic schools that teach stuff like anatomy, physiology, microbiology, etc. from the scratch? Seems strange that paramedic schools would have entrance requirements in those subjects when even medical schools don't (since it's in their curriculum).

Wouldn't federal loans be the best bet? Their requirement for an accredited college may seem like a hindrance, but wouldn't you want to get your education in an accredited college anyway? Anyway, the way I'm getting through medical school (and two of my friends are actually doing the same for paramedic school in Detroit), is through state-sponsored loans (Icelandic, the following terms may not apply to the US federal loans). The loans we get are fixed amounts for living expenses, books, and traveling (traveling, since we're studying abroad). Also, they loan us money for tuition fees, minus about $650 USD per year, which we have to pay out of the pocket. Extra loans are available if we're providing for a spouse, children, elderly parents, etc. There's a maximum amount they give us for tuition fees, though. My six years will go close to that maximum, but won't quite reach it. The loans don't carry any interest while we're in school, but immediately after graduation (or if we drop out), they start collecting 1% interest. We don't have to start paying back until 2 years after graduation (or drop-out), and then we just have an annual payment of about 3-4% of our salary. If we can't find a job, lose it, get sick or injured and can't work, etc., the 3-4% boils down to a very small payment. If we die before we finish paying off the loan, it simply expires, they write it off. One caveat, though. They only give us the loan after we've finished each semester, and then only if we've passed 75% or more of what is considered full time study (30 ECTS units per semester*). This means we have to get a loan from a bank and then repay the bank after each semester (living expenses) or school year (tutition fees). * ECTS = European Credit Transfer System. Each credit unit corresponds to roughly 30 hours of work for an average student.

Well, everyone who's ever been in university knows that most classes are just a waste of time that could have been used studying. That said, there is a certain guarantee involved if you have to be physically present when certain things are covered. Also, in medical school, most subjects have labs. Anatomy, dissection labs, histology, excruciatingly boring times with the microscopes, biochemistry, physiology, the list goes on. Those definitely require physical presence. Keep a job during medical school? You must be kidding. I know a lot of medical students in at least two countries and I don't know of anyone who works when school is in session. Obviously, we all work 90-100 hour weeks during summer and christmas breaks, but not while we're at school. Doesn't that take away the positive parts of studying online? I mean, in my school lecture attendance is mostly not compulsory (seminars and labs are, though), and lecture slides are available at the department's websites...does that mean my school is providing "online education"? I'm not sure. How about asking questions? Maybe I'm just old-fashioned, I usually don't even go to lectures, so I guess I wouldn't mind if they were online...

Since we're on the subject, anyone care to enlighten a foreigner on the difference between a DO and an MD? I always thought they were both doctors, just different styles of basically the same medical education - "than 20 years ago, when a D.O. was not allowed to work in the E.D. " - does that mean that DO is a lower degree, maybe something between PA and MD? Apparently, it's just not in EMS you guys have a lot of levels - I'm used to only EMT (mostly) -> nurse's aid -> nurse -> doctor...

Call me old-fashioned, but I'm a bit prejudiced against them. Haven't ever heard of a quality online MD school and I have a hard time visioning one.